Declaration Of Status Of Dependents Page 2
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1
2(If any)?
10A. IS YOUR SPOUSE ALSO A VETERAN?
10B. WHAT IS YOUR SPOUSE'S VA FILE NUMBER
(If "Yes," answer Item 10B also. If "No," skip to Item 11.)
YES
NO
11. DO YOU LIVE WITH YOUR SPOUSE?
12. WHAT IS YOUR SPOUSE'S ADDRESS?
(If "Yes," skip to Item 14A. If "No, answer Items 12 and
YES
NO
13 also.)
13. HOW MUCH DO YOU CONTRIBUTE MONTHLY TO YOUR SPOUSE'S SUPPORT?
$
SECTION III - VETERAN'S UNMARRIED CHILDREN
NOTE: If any child is claimed as "seriously disabled" (Item 14H), it must be shown that the child became permanently unable to support him/herself
before reaching age 18. Furnish a statement from an attending physician or other medical evidence which shows the nature and extent of the
physical or mental impairment.
Note: In Items 14A through 14I, check all boxes that apply.
14B.
14C.
14G.
14I.
14A.
14D.
14E.
14F.
14H.
DATE AND PLACE
SOCIAL
18-23 YRS.
CHILD
NAME OF CHILD
BIO -
ADOPT -
STEP -
SERIOUSLY
OF BIRTH
SECURITY
OLD AND IN
PREVIOUSLY
LOGICAL
ED
CHILD
DISABLED
(first, middle initial, last)
SCHOOL
MARRIED
(city, state or country)
NUMBER
mo day yr
PLACE:
mo day yr
PLACE:
mo day yr
PLACE:
14J. IF YOU CHECKED "STEPCHILD," IS THE STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?
YES
NO
Note: If any of the children listed above don't live with you, complete Items 15A through 15C.
15A. NAME OF CHILD
15C. NAME OF PERSON THE CHILD
15B. CHILD'S COMPLETE ADDRESS
(First, middle initial, last)
LIVES WITH (If applicable)
16. REMARKS
I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.
(Claimant, please sign in ink)
19. TELEPHONE NUMBER(S) (Include Area Code)
17. SIGNATURE OF CLAIMANT
18. DATE
A. DAYTIME
B. NIGHTTIME
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence
of a material fact, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-686c, JUN 2014
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